Patient with toe pain after a playground injury. XR reveals a displaced fracture involving half the joint surface of the first proximal phalanx.
What should you do? Answer: Prompt orthopedic referral for surgical fixation.
“Phalangeal fractures of the second to fifth toes can usually be managed with buddy taping and a rigid-sole shoe for 3 weeks followed by buddy taping for another 3 weeks. If the fracture is significantly displaced, closed reduction in the office using local anesthesia may be appropriate. However, because of its importance in weight bearing and balance, fractures of the first toe (hallux) have a higher potential for negative outcomes. Specifically, fractures of the hallux can be managed nonsurgically if they are not displaced and involve less than 25% of the articular surface of the joint. Nonsurgical
management involves use of a short leg walking cast with a toe plate (extending past the end of the great toe) for 3 weeks and then progression to a rigid-sole shoe with buddy taping after that. Since this patient’s fracture involves more than 25% of the articular surface of the joint of the first toe, early referral for surgical pinning by an orthopedic surgeon would lead to the best outcome.
Ref: Marx JA, Hockberger RS, Walls RM (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. Elsevier Saunders, 2014, pp 723-750. 2) Bica D, Sprouse RA, Armen J: Diagnosis and management of common foot fractures. Am Fam Physician 2016;93(3):183-191.” ABFM